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Wharam JF, Newhouse JP. High-Deductible Insurance and Delay in Care. Ann Intern Med 2019; 171:226. [PMID: 31382282 DOI: 10.7326/l19-0205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- J Frank Wharam
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston Massachusetts (J.F.W.)
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Gaffney A, Christopher A, Katz A, Chateau D, McDougall C, Bor D, Himmelstein D, Woolhandler S, McCormick D. The Incidence of Diabetic Ketoacidosis During "Emerging Adulthood" in the USA and Canada: a Population-Based Study. J Gen Intern Med 2019; 34:1244-1250. [PMID: 31065950 PMCID: PMC6614229 DOI: 10.1007/s11606-019-05006-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 12/20/2018] [Accepted: 03/20/2019] [Indexed: 03/17/2023]
Abstract
BACKGROUND As children with diabetes transition to adulthood, they may be especially vulnerable to diabetic ketoacidosis (DKA). Cross-national comparisons may inform efforts to avoid this complication. OBJECTIVE To compare DKA hospitalization rates in the USA and Manitoba, Canada, during the vulnerable years known as "emerging adulthood." DESIGN Cross-sectional study using inpatient administrative databases in the USA (years 1998-2014) and Manitoba, Canada (years 2003-2013). PARTICIPANTS Individuals aged 12-30 years hospitalized with DKA, identified using ICD-9 (USA) or ICD-10 codes (Manitoba). MAIN MEASURES DKA hospitalization rates per 10,000 population by age (with a focus on those aged 15-17 vs. 19-21). Admissions were characterized by gender, socioeconomic status, year of hospitalization, and mortality during hospitalization. KEY RESULTS The DKA rate was slightly higher in the USA among those aged 15-17: 4.8 hospitalizations/10,000 population vs. 3.7/10,000 in Manitoba. Among those aged 19-21, the DKA hospitalization rate rose 90% in the USA to 9.2/10,000, vs. 23% in Manitoba, to 4.5/10,000. In both the USA and Manitoba, rates were higher among those from poorer areas, and among adolescent girls compared with adolescent boys. DKA admissions rose gradually during the period under study in the USA, but not in Manitoba. CONCLUSIONS In years of "emerging adulthood," the Canadian healthcare system appears to perform better than that of the USA in preventing hospitalizations for DKA. Although many factors likely contribute to this difference, universal and seamless coverage over the lifespan in Canada may contribute.
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Affiliation(s)
- Adam Gaffney
- Cambridge Health Alliance/Harvard Medical School, 1493 Cambridge Street, Cambridge, MA, 02138, USA.
| | - Andrea Christopher
- Boise Veterans Affairs Medical Center, University of Washington School of Medicine, Seattle, USA.
| | - Alan Katz
- Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Canada
| | - Dan Chateau
- Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Canada
| | - Chelsey McDougall
- Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Canada
| | - David Bor
- Cambridge Health Alliance/Harvard Medical School, 1493 Cambridge Street, Cambridge, MA, 02138, USA
| | - David Himmelstein
- Cambridge Health Alliance/Harvard Medical School, 1493 Cambridge Street, Cambridge, MA, 02138, USA.,City University of New York at Hunter College, New York, USA
| | - Steffie Woolhandler
- Cambridge Health Alliance/Harvard Medical School, 1493 Cambridge Street, Cambridge, MA, 02138, USA.,City University of New York at Hunter College, New York, USA
| | - Danny McCormick
- Cambridge Health Alliance/Harvard Medical School, 1493 Cambridge Street, Cambridge, MA, 02138, USA
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Garabedian LF, Ross-Degnan D, Wharam JF. Provider Perspectives on Quality Payment Programs Targeting Diabetes in Primary Care Settings. Popul Health Manag 2019; 22:248-254. [PMID: 30204544 PMCID: PMC6555171 DOI: 10.1089/pop.2018.0093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Public and private insurers increasingly use quality payment programs as a tool to improve quality of care in primary care settings. However, little is known about primary care providers' perspectives on whether and how quality payment programs improve diabetes quality of care. In this qualitative study, the authors conducted semi-structured interviews and focus groups with 23 providers from March to June 2015. Transcripts were analyzed to identify key themes using the immersion-crystallization method. Almost all of the providers believed that insurers play a meaningful role in improving quality of care for diabetes patients. Most thought that insurers' efforts are more effective when channeled through providers and delivery systems rather than directed at patients. Providers generally believed that quality payment programs have had a positive impact on quality of diabetes care, although provider views were not evidence based. Providers in practices in which quality payment programs were believed to have had a positive impact stated that the programs provided financial incentives and resources for improved population health management systems and additional staff. Conversely, most providers did not believe that quality payment programs have had any impact via direct financial incentives to individual physicians. A few providers were skeptical about the impact of quality payment programs and noted negative consequences that they had observed. Providers recommended strategies to improve quality payment programs (eg, refine quality measures, provide regular feedback on quality and costs) and additional strategies that insurers could consider to address provider- and patient-level barriers to high-quality diabetes care.
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Affiliation(s)
- Laura F. Garabedian
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - James F. Wharam
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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Barry CL, Kennedy-Hendricks A, Mandell D, Epstein AJ, Candon M, Eisenberg M. State Mandate Laws for Autism Coverage and High-Deductible Health Plans. Pediatrics 2019; 143:e20182391. [PMID: 31092588 PMCID: PMC6564055 DOI: 10.1542/peds.2018-2391] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Most states have passed insurance mandates requiring health plans to cover services for children with autism spectrum disorder (ASD). Research reveals that these mandates increased treated prevalence, service use, and spending on ASD-related care. As employer-sponsored insurance shifts toward high-deductible health plans (HDHPs), it is important to understand how mandates affect children with ASD in HDHPs relative to traditional, low-deductible plans. METHODS Insurance claims for 2008-2012 for children covered by 3 large US insurers (United Healthcare, Aetna, and Humana) available through the Health Care Cost Institute were used to compare the effects of mandates on ASD-related spending for children in HDHPs and traditional health plans. RESULTS Relative to children in traditional plans, mandates were associated with higher average monthly spending increases for children in HDHPs. Mandate-attributable spending differences between children enrolled in HDHPs relative to traditional plans were $77 for ASD-specific services (95% confidence interval [CI]: $10 to $144), $125 for outpatient health services (95% CI: $26 to $223), and $144 for all health services (95% CI: $36 to $253). These spending differentials were driven by differences in plan spending and not out-of-pocket (OOP) spending. CONCLUSIONS Spending on ASD-related services attributable to autism mandates was higher among children in HDHPs, but higher spending did not translate into a greater OOP burden. For families with consistently high health care expenditures on ASD-related services, high-deductible products may be worth considering in the context of mandate laws. Families in mandate states with children with ASD enrolled in HDHPs were able to increase service use without paying more OOP.
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Affiliation(s)
- Colleen L Barry
- Department of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland;
- Johns Hopkins Center for Mental Health and Addiction Policy Research, Baltimore, Maryland
- Leonard Davis Institute of Health Economics and
| | - Alene Kennedy-Hendricks
- Department of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland
- Johns Hopkins Center for Mental Health and Addiction Policy Research, Baltimore, Maryland
| | - David Mandell
- Leonard Davis Institute of Health Economics and
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | | | - Molly Candon
- Leonard Davis Institute of Health Economics and
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Matthew Eisenberg
- Department of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland
- Johns Hopkins Center for Mental Health and Addiction Policy Research, Baltimore, Maryland
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Abstract
High-deductible health plans (HDHPs) are becoming more popular owing to their potential to curb rising health care costs. Relative to traditional health insurance plans, HDHPs involve higher out-of-pocket costs for consumers, which have been associated with lower utilization of health services. We focus specifically on the impact that HDHPs have on the use of preventive services. We critique the current evidence by discussing the benefits and drawbacks of the research designs used to examine this relationship. We also summarize the findings from the most methodologically sophisticated studies. We conclude that the balance of the evidence shows that HDHPs are reducing the use of some preventive service, especially screenings. However, it is not clear if HDHPs affect all preventive services. Additional research is needed to determine why variability in conclusions exists among studies. We describe an agenda for future research that can further inform public health decision makers on the impact of HDHPs on prevention.
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Affiliation(s)
- Olena Mazurenko
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University-IUPUI, Indianapolis, Indiana 46202-2872, USA;,
| | - Melinda J.B. Buntin
- Department of Health Policy, School of Medicine, Vanderbilt University, Nashville, Tennessee 37203, USA
| | - Nir Menachemi
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University-IUPUI, Indianapolis, Indiana 46202-2872, USA;,
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Wharam JF, Zhang F, Wallace J, Lu C, Earle C, Soumerai SB, Nekhlyudov L, Ross-Degnan D. Vulnerable And Less Vulnerable Women In High-Deductible Health Plans Experienced Delayed Breast Cancer Care. Health Aff (Millwood) 2019; 38:408-415. [PMID: 30830830 PMCID: PMC7268048 DOI: 10.1377/hlthaff.2018.05026] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The effects of high-deductible health plans (HDHPs) on breast cancer diagnosis and treatment among vulnerable populations are unknown. We examined time to first breast cancer diagnostic testing, diagnosis, and chemotherapy among a group of women whose employers switched their insurance coverage from health plans with low deductibles ($500 or less) to plans with high deductibles ($1,000 or more) between 2004 and 2014. Primary subgroups of interest comprised 54,403 low-income and 76,776 high-income women continuously enrolled in low-deductible plans for a year and then up to four years in HDHPs. Matched controls had contemporaneous low-deductible enrollment. Low-income women in HDHPs experienced relative delays of 1.6 months to first breast imaging, 2.7 months to first biopsy, 6.6 months to incident early-stage breast cancer diagnosis, and 8.7 months to first chemotherapy. High-income HDHP members had shorter delays that did not differ significantly from those of their low-income counterparts. HDHP members living in metropolitan, nonmetropolitan, predominantly white, and predominantly nonwhite areas also experienced delayed breast cancer care. Policies may be needed to reduce out-of-pocket spending obligations for breast cancer care.
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Affiliation(s)
- J Frank Wharam
- J. Frank Wharam ( ) is an associate professor in and director of the Division of Health Policy and Insurance Research, Department of Population Medicine, at Harvard Medical School and the Harvard Pilgrim Health Care Institute, in Boston, Massachusetts
| | - Fang Zhang
- Fang Zhang is an assistant professor in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute
| | - Jamie Wallace
- Jamie Wallace is a project manager in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute
| | - Christine Lu
- Christine Lu is an associate professor in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute
| | - Craig Earle
- Craig Earle is a professor of medicine at IC/ES, in Toronto, Ontario
| | - Stephen B Soumerai
- Stephen B. Soumerai is a professor in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute
| | - Larissa Nekhlyudov
- Larissa Nekhlyudov is an associate professor of medical oncology at the Dana-Farber Cancer Institute, in Boston
| | - Dennis Ross-Degnan
- Dennis Ross-Degnan is an associate professor in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute
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Wharam JF, Lu CY, Zhang F, Callahan M, Xu X, Wallace J, Soumerai S, Ross-Degnan D, Newhouse JP. High-Deductible Insurance and Delay in Care for the Macrovascular Complications of Diabetes. Ann Intern Med 2018; 169:845-854. [PMID: 30458499 PMCID: PMC6934173 DOI: 10.7326/m17-3365] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Little is known about the long-term effects of high-deductible insurance on care for chronic medical conditions. OBJECTIVE To determine whether a transition from low-deductible to high-deductible insurance is associated with delayed medical care for macrovascular complications of diabetes. DESIGN Observational longitudinal comparison of matched groups. SETTING A large national health insurer during 2003 to 2012. PARTICIPANTS The intervention group comprised 33 957 persons with diabetes who were continuously enrolled in low-deductible (≤$500) insurance plans during a baseline year followed by up to 4 years in high-deductible (≥$1000) plans. The control group included 294 942 persons with diabetes who were enrolled in low-deductible plans contemporaneously with matched intervention group members. INTERVENTION Employer-mandated transition to a high-deductible plan. MEASUREMENTS The number of months it took for persons in each study group to seek care for their first major macrovascular symptom, have their first major diagnostic test for macrovascular disease, and have their first major procedure-based treatment was determined. Between-group differences in time to reach a midpoint event rate were then calculated. RESULTS No baseline differences were found between groups. During follow-up, the delay for the high-deductible group was 1.5 months (95% CI, 0.8 to 2.3 months) for seeking care for the first major symptom, 1.9 months (CI, 1.4 to 2.3 months) for the first diagnostic test, and 3.1 months (CI, 0.5 to 5.8 months) for the first procedure-based treatment. LIMITATION Health outcomes were not examined. CONCLUSION Among persons with diabetes, mandated enrollment in a high-deductible insurance plan was associated with delays in seeking care for the first major symptoms of macrovascular disease, the first diagnostic test, and the first procedure-based treatment. PRIMARY FUNDING SOURCE National Institute of Diabetes and Digestive and Kidney Diseases.
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Affiliation(s)
- J Frank Wharam
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (J.F.W., C.Y.L., F.Z., M.C., X.X., J.W., S.S., D.R.)
| | - Christine Y Lu
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (J.F.W., C.Y.L., F.Z., M.C., X.X., J.W., S.S., D.R.)
| | - Fang Zhang
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (J.F.W., C.Y.L., F.Z., M.C., X.X., J.W., S.S., D.R.)
| | - Matthew Callahan
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (J.F.W., C.Y.L., F.Z., M.C., X.X., J.W., S.S., D.R.)
| | - Xin Xu
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (J.F.W., C.Y.L., F.Z., M.C., X.X., J.W., S.S., D.R.)
| | - Jamie Wallace
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (J.F.W., C.Y.L., F.Z., M.C., X.X., J.W., S.S., D.R.)
| | - Stephen Soumerai
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (J.F.W., C.Y.L., F.Z., M.C., X.X., J.W., S.S., D.R.)
| | - Dennis Ross-Degnan
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (J.F.W., C.Y.L., F.Z., M.C., X.X., J.W., S.S., D.R.)
| | - Joseph P Newhouse
- Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, and Harvard Kennedy School and National Bureau of Economic Research, Cambridge, Massachusetts (J.P.N.)
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Ali MK, Wharam F, Kenrik Duru O, Schmittdiel J, Ackermann RT, Albu J, Ross-Degnan D, Hunter CM, Mangione C, Gregg EW. Advancing Health Policy and Program Research in Diabetes: Findings from the Natural Experiments for Translation in Diabetes (NEXT-D) Network. Curr Diab Rep 2018; 18:146. [PMID: 30456479 PMCID: PMC6640642 DOI: 10.1007/s11892-018-1112-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW To advance our understanding of the impacts of policies and programs aimed at improving detection, engagement, prevention, and clinical diabetes management in the USA, we synthesized findings from a network of studies that used natural experiments to evaluate diabetes health policies and programs. FINDINGS Studies from the Natural EXperiments for Translation in Diabetes (NEXT-D) network used rigorous longitudinal quasi-experimental study designs (e.g., interrupted time series) and analytical methods (e.g., difference-in-differences) to augment causal inference. Investigators partnered with health system stakeholders to evaluate whether glucose testing rates changed from before-to-after clinic interventions (e.g., integrating electronic screening decision prompts in New York City) or employer programs (e.g., targeted messaging and waiving copayments for at-risk employees). Other studies examined participation and behavior change in low- (e.g., wellness coaching) or high-intensity lifestyle modification programs (e.g., diabetes prevention program-like interventions) offered by payers or employers. Lastly, studies assessed how employer health insurance benefits impacted healthcare utilization, adherence, and outcomes among people with diabetes. NEXT-D demonstrated that low-intensity interventions to facilitate glucose testing and enhance engagement in lifestyle modification were associated with small improvements in weight but large improvements in screening and testing when supported by electronic health record-based decision-support. Regarding high-intensity diabetes prevention program-like lifestyle programs offered by payers or employers, enrollment was modest and led to weight loss and marginally lower short-term health expenditures. Health plans that incentivize patient behaviors were associated with increases in medication adherence. Meanwhile, shifting patients to high-deductible health plans was associated with no change in medication use and preventive screenings, but patients with diabetes delayed accessing healthcare for acute complications (e.g., cellulitis). Findings were more pronounced among lower-income patients, who experienced increased rates and acuity of emergency department visits for diabetes complications and other high-severity conditions. Findings from NEXT-D studies provide informative data that can guide programs and policies to facilitate detection, prevention, and treatment of diabetes in practice.
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Affiliation(s)
- Mohammed K Ali
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Mailstop K10, 4770 Buford Highway, Atlanta, GA, 30341, USA.
- Hubert Department of Global Health, Emory University, 1518 Clifton Road NE, Ste 7041 CNR Building, Atlanta, GA, 30322, USA.
| | - Frank Wharam
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, 401 Park Drive, Suite 401 East, Boston, MA, 02215, USA
| | - O Kenrik Duru
- Division of General Internal Medicine, University of California Los Angeles, 911 Broxton Ave., Los Angeles, CA, 90024, USA
| | - Julie Schmittdiel
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Ronald T Ackermann
- Department of Medicine, General Medicine Division, Northwestern University, Rubloff Building 10th Floor 750 N Lake Shore, Chicago, IL, 60611, USA
| | - Jeanine Albu
- Division of Endocrinology, Diabetes and Bone Diseases, Icahn School of Medicine at Mount Sinai, 1111 Amsterdam Avenue Babcock Building - 10th Floor, New York, NY, 10025, USA
| | - Dennis Ross-Degnan
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, 401 Park Drive, Suite 401 East, Boston, MA, 02215, USA
| | - Christine M Hunter
- Office of Behavioral and Social Sciences Research, National Institutes of Health, 31 Center Drive, Bethesda, MD, 20892, USA
| | - Carol Mangione
- Division of General Internal Medicine, University of California Los Angeles, UCLA Med-GIM & HSR BOX 957394, 10940 Wilshire Blvd, Los Angeles, CA, 90095, USA
| | - Edward W Gregg
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Mailstop K10, 4770 Buford Highway, Atlanta, GA, 30341, USA
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Total and out-of-pocket expenditures among women with metastatic breast cancer in low-deductible versus high-deductible health plans. Breast Cancer Res Treat 2018; 171:449-459. [PMID: 29855813 DOI: 10.1007/s10549-018-4819-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/03/2018] [Indexed: 01/23/2023]
Abstract
PURPOSE High-deductible health plan (HDHP) enrollment is expanding rapidly and might substantially increase out-of-pocket (OOP) payment burden. We examined trends in total and OOP health service expenditures overall and by insurance coverage type among women with metastatic breast cancer. METHODS We used a longitudinal time series design to examine measures among 5364 women with metastatic breast cancer insured by a large US health insurer from 2004 to 2011. We measured outcomes during the 12 months after a first identified metastatic breast cancer diagnosis and required women to have at least 6 months of prior enrollment. We plotted enrollment measures and adjusted total and OOP spending. We fit trend lines using linear autoregressive models. RESULTS Between 2004 and 2011, the percentage of women with metastatic breast cancer enrolled in employer-mandated HDHPs increased from 8 to 23% while the percentage enrolled in employer-mandated low-deductible plans (LDHPs) decreased from 69 to 37%. Over the same time period, estimated annual inflation-adjusted total health service spending among women with metastatic breast cancer whose employers only offered HDHPs or LDHPS increased from $96,899 to $104,688 (increase of $1197 per year; 95% confidence interval [CI]: $47,$2,348). Corresponding OOP spending values among these women with employer-mandated deductible levels were $4,496 and $5,151 ($91 per year trend; 95% CI -$13,$195). From 2004-2011, women in HDHPs and LDHPs had unchanged annual OOP spending, estimated at of $6642 (95% CI $6,268,$7016) and $4,247 (95% CI $3956,$4538), respectively. Thus, women in HDHPs experienced 55% (44%, 66%) more OOP spending than women in LDHP. CONCLUSIONS OOP spending among women with metastatic breast cancer and employer-mandated deductible levels was 55% higher among HDHP than LDHP members, and employer-mandated HDHP enrollment increased substantially from 2004 to 2011. Stakeholders and policymakers should design health plans that protect financially vulnerable cancer patients from high OOP costs.
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Impact of high-deductible insurance on adjuvant hormonal therapy use in breast cancer. Breast Cancer Res Treat 2018; 171:235-242. [PMID: 29754304 DOI: 10.1007/s10549-018-4821-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/03/2018] [Indexed: 10/16/2022]
Abstract
OBJECTIVE High-deductible health plans (HDHPs) have become the predominant commercial health insurance arrangement in the US. HDHPs require substantial out-of-pocket (OOP) costs for most services but often exempt medications from high cost sharing. We examined effects of HDHPs on OOP costs and utilization of adjuvant hormonal therapy (AHT), which are fundamental care for patients with breast cancer. METHODS This controlled quasi-experimental study used claims data (2003-2012) from a large national health insurer. We included 986 women with incident early-stage breast cancer, age 25-64 years, insured by employers that mandated a transition from low-deductible (≤ $500/year) to high-deductible (≥ $1000/year) coverage, and 3479 propensity score-matched controls whose employers offered only low-deductible plans. We examined AHT utilization and OOP costs per person-year before and after the HDHP switch. RESULTS At baseline, the OOP costs for AHT were $40.41 and $36.55 per person-year among the HDHP and control groups. After the HDHP switch, the OOP costs for AHT were $91.76 and $72.98 per person-year among the HDHP and control groups, respectively. AHT OOP costs increased among HDHP members relative to controls but the change was not significant (relative change 13.72% [95% CI - 9.25, 36.70%]). AHT use among HDHP members did not change compared to controls (relative change of 2.73% [95% CI - 14.01, 19.48%]); the change in aromatase inhibitor use was - 11.94% (95% CI - 32.76, 8.88%) and the change in tamoxifen use was 20.65% (95% CI - 8.01, 49.32%). CONCLUSION We did not detect significant changes in AHT use after the HDHP switch. Findings might be related to modest increases in overall AHT OOP costs, the availability of low-cost generic tamoxifen, and patient awareness that AHT can prolong life and health. Minimizing OOP cost increases for essential medications might represent a feasible approach for maintaining medication adherence among HDHP members with incident breast cancer.
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Wharam JF, Zhang F, Eggleston EM, Lu CY, Soumerai SB, Ross-Degnan D. Effect of High-Deductible Insurance on High-Acuity Outcomes in Diabetes: A Natural Experiment for Translation in Diabetes (NEXT-D) Study. Diabetes Care 2018; 41:940-948. [PMID: 29382660 PMCID: PMC5911790 DOI: 10.2337/dc17-1183] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 12/19/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE High-deductible health plans (HDHPs) are now the predominant commercial health insurance benefit in the U.S. We sought to determine the effects of HDHPs on emergency department and hospital care, adverse outcomes, and total health care expenditures among patients with diabetes. RESEARCH DESIGN AND METHODS We applied a controlled interrupted time-series design to study 23,493 HDHP members with diabetes, aged 12-64, insured through a large national health insurer from 2003 to 2012. HDHP members were enrolled for 1 year in a low-deductible (≤$500) plan, followed by 1 year in an HDHP (≥$1,000 deductible) after an employer-mandated switch. Patients transitioning to HDHPs were matched to 192,842 contemporaneous patients whose employers offered only low-deductible coverage. HDHP members from low-income neighborhoods (n = 8,453) were a subgroup of interest. Utilization measures included emergency department visits, hospitalizations, and total (health plan plus member out-of-pocket) health care expenditures. Proxy health outcome measures comprised high-severity emergency department visit expenditures and high-severity hospitalization days. RESULTS After the HDHP transition, emergency department visits declined by 4.0% (95% CI -7.8, -0.1), hospitalizations fell by 5.6% (-10.8, -0.5), direct (nonemergency department-based) hospitalizations declined by 11.1% (-16.6, -5.6), and total health care expenditures dropped by 3.8% (-4.3, -3.4). Adverse outcomes did not change in the overall HDHP cohort, but members from low-income neighborhoods experienced 23.5% higher (18.3, 28.7) high-severity emergency department visit expenditures and 27.4% higher (15.5, 39.2) high-severity hospitalization days. CONCLUSIONS After an HDHP switch, direct hospitalizations declined by 11.1% among patients with diabetes, likely driving 3.8% lower total health care expenditures. Proxy adverse outcomes were unchanged in the overall HDHP population with diabetes, but members from low-income neighborhoods experienced large, concerning increases in high-severity emergency department visit expenditures and hospitalization days.
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Affiliation(s)
- J Frank Wharam
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Fang Zhang
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Emma M Eggleston
- Department of Medicine, West Virginia University Health Sciences Center, Morgantown, WV
| | - Christine Y Lu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Stephen B Soumerai
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
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Duru OK, Mangione CM, Rodriguez HP, Ross-Degnan D, Wharam JF, Black B, Kho A, Huguet N, Angier H, Mayer V, Siscovick D, Kraschnewski JL, Shi L, Nauman E, Gregg EW, Ali MK, Thornton P, Clauser S. Introductory Overview of the Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) Network: Examining the Impact of US Health Policies and Practices to Prevent Diabetes and Its Complications. Curr Diab Rep 2018; 18:8. [PMID: 29399715 PMCID: PMC8910460 DOI: 10.1007/s11892-018-0977-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Diabetes incidence is rising among vulnerable population subgroups including minorities and individuals with limited education. Many diabetes-related programs and public policies are unevaluated while others are analyzed with research designs highly susceptible to bias which can result in flawed conclusions. The Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) Network includes eight research centers and three funding agencies using rigorous methods to evaluate natural experiments in health policy and program delivery. RECENT FINDINGS NEXT-D2 research studies use quasi-experimental methods to assess three major areas as they relate to diabetes: health insurance expansion; healthcare financing and payment models; and innovations in care coordination. The studies will report on preventive processes, achievement of diabetes care goals, and incidence of complications. Some studies assess healthcare utilization while others focus on patient-reported outcomes. NEXT-D2 examines the effect of public and private policies on diabetes care and prevention at a critical time, given ongoing and rapid shifts in the US health policy landscape.
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Affiliation(s)
- O Kenrik Duru
- Division of General Internal Medicine & Health Services Research, David Geffen School of Medicine, UCLA, 10940 Wilshire Blvd., Suite 700, Los Angeles, CA, 90024, USA.
| | - Carol M Mangione
- David Geffen School of Medicine at UCLA and Fielding School of Public Health, UCLA, Los Angeles, CA, USA
| | - Hector P Rodriguez
- School of Public Health - Health Policy and Management, University of California, Berkeley, Berkeley, CA, USA
| | - Dennis Ross-Degnan
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - J Frank Wharam
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Bernard Black
- Pritzker School of Law, Institute for Policy Research, and Kellogg School of Management, Northwestern University, Evanston, IL, USA
| | - Abel Kho
- Institute of Public Health & Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Victoria Mayer
- Department of Population Health Science and Policy, Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Jennifer L Kraschnewski
- Department of Medicine, Pediatrics and Public Health Sciences, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
| | - Lizheng Shi
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | | | - Edward W Gregg
- Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, GA, USA
| | - Mohammed K Ali
- Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Pamela Thornton
- Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Disease, Bethesda, MD, USA
| | - Steven Clauser
- Health Care Delivery and Disparities Research Program, Patient-Centered Outcomes Research Institute, Washington, DC, USA
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Reid RO, Rabideau B, Sood N. Impact of consumer-directed health plans on low-value healthcare. THE AMERICAN JOURNAL OF MANAGED CARE 2017; 23:741-748. [PMID: 29261240 PMCID: PMC6132267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To assess the impact of consumer-directed health plan (CDHP) enrollment on low-value healthcare spending. STUDY DESIGN We performed a quasi-experimental analysis using insurance claims data from 376,091 patients aged 18 to 63 years continuously enrolled in a plan from a large national commercial insurer from 2011 to 2013. We measured spending on 26 low-value healthcare services that offer unclear or no clinical benefit. METHODS Employing a difference-in-differences approach, we compared the change in spending on low-value services for patients switching from a traditional health plan to a CDHP with the change in spending on low-value services for matched patients remaining in a traditional plan. RESULTS Switching to a CDHP was associated with a $231.60 reduction in annual outpatient spending (95% CI, -$341.65 to -$121.53); however, no significant reductions were observed in annual spending on the 26 low-value services (--$3.64; 95% CI, -$9.60 to $2.31) or on these low-value services relative to overall outpatient spending (-$7.86 per $10,000 in outpatient spending; 95% CI, -$18.43 to $2.72). Similarly, a small reduction was noted for low-value spending on imaging (-$1.76; 95% CI, -$3.39 to -$0.14), but not relative to overall imaging spending, and no significant reductions were noted in low-value laboratory spending. CONCLUSIONS CDHPs in their current form may represent too blunt an instrument to specifically curtail low-value healthcare spending.
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Affiliation(s)
| | | | - Neeraj Sood
- University of Southern California, Verna and Peter Dauterive Hall 210, 635 Downey Way, Los Angeles, CA 90089. E-mail:
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Himmelstein DU, Woolhandler S, Almberg M, Fauke C. The U.S. Health Care Crisis Continues: A Data Snapshot. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2017; 48:28-41. [PMID: 29182038 DOI: 10.1177/0020731417741779] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite implementation of the Affordable Care Act in 2014, the U.S. health care crisis continues. While coverage has been expanded, 28 million people remain uninsured, and tens of millions who have coverage are unable to afford care because of high cost-sharing requirements. Moreover, many with coverage have a sharply restricted choice of physicians and hospitals, and the corporate takeover of medical care in the United States is proceeding rapidly. This article provides a brief précis of recent data on U.S. health policy.
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Affiliation(s)
- David U Himmelstein
- 1 Hunter College, City University of New York, New York, NY, USA.,2 Harvard Medical School, Boston, MA, USA
| | - Steffie Woolhandler
- 1 Hunter College, City University of New York, New York, NY, USA.,2 Harvard Medical School, Boston, MA, USA
| | - Mark Almberg
- 3 Physicians for a National Health Program, Chicago, Illinois, USA
| | - Clare Fauke
- 3 Physicians for a National Health Program, Chicago, Illinois, USA
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Abstract
PURPOSE OF REVIEW Patients with diabetes must deal with the burden of symptoms and complications (burden of illness). Simultaneously, diabetes care demands practical and emotional work from patients and their families, work to access and use healthcare and to enact self-care (burden of treatment). Patient work must compete with the demands of family, job, and community life. Overwhelmed patients may not have the capacity to access care or enact self-care and will thus experience suboptimal diabetes outcomes. RECENT FINDINGS Minimally disruptive medicine (MDM) is a patient-centered approach to healthcare that prioritizes patients' goals for life and health while minimizing the healthcare disruption on patients' lives. In patients with diabetes, particularly in those with complex lives and multimorbidity, MDM coordinates healthcare and community responses to improve outcomes, reduce treatment burden, and enable patients to pursue their life's hopes and dreams.
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Affiliation(s)
- Valentina Serrano
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
- Department of Nutrition, Diabetes and Metabolism, Escuela de Medicina Pontificia Universidad Católica de Chile, Alameda Libertador Bernardo O'Higgins 340, Santiago, Chile
| | - Gabriela Spencer-Bonilla
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
- Mayo Graduate School, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
- School of Medicine, University of Puerto Rico Medical Sciences Campus, PO Box 365067, San Juan, PR, 00936, USA
| | - Kasey R Boehmer
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.
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